Medical History: (Are there any medical conditions your child has that the staff needs to be aware of? List medications your child is presently taking.)*

Parents' or Guardian

Parents' or Guardian's Names*

First

Last

Address

Same as previous

Street Address

Address Line 2

City

State

ZIP Code

Parent's Email*

Enter Email

Confirm Email

Dad's Cell Phone

Mom's Cell Phone

Home Phone

Emergency Contact Name/Phone (Other than parent/guardian):

Name*

First

Last

Relationship*

Phone*

Photo Release: (Please initial here)*

Photos and video will be taken and shared during activities through bulletin boards, the church website and other promotional materials with our church family. At no time will names or personal information be shared concerning who is a part of the group nor in a photograph. If you would allow your child to be photographed for this purpose, please initial here:

Medical and Liability Release: (Enter Child's Name)*

We realize that no activity is without the possibility of unforeseen hazards which could result in injury to an individual. As a parent or guardian, you are to be aware of your responsibility to instruct your child of the importance of conduct which will insure safety and enjoyable time while participating in this activity. By signing this form, you, as a parent, guardian or other responsible party, agree to assume the risks and hazards which are inherent in this kind of activity. You also agree to absolve and hold harmless the sponsoring organizations and their representatives for damage, loss or injuries to the child for whom you sign.

I give my child permission to participate in this activity, and give my permission to the leaders of this function to authorize any treatment deemed necessary by a licensed physician due to accident or illness during this activity.

(For all activities away from the church premises, a medical
release/covenant of conduct form must be on file with CSM (see the link on
the CSM page). Please attach a copy of your child’s insurance card to the
printed form.)

Parent's/Guardian Signature:*

First

Last

By entering your name here you are authorizing this with a digital signature.